Prior Authorization Medical Clinician

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive the appropriate and timely care to support members in achieving optimal health outcomes.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual criteria, Medical Policy and benefit determination.

* Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.

* Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria

* Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

* Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.

* Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.

* Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).

* Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.

* Sends appropriate system-generated letters to provider and member

* Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses

* Follows all departmental policies and workflows in end-to-end management of cases.

* Participates in team meetings, education, discussions, and related activities

* Maintains compliance with Federal, State and accreditation organizations.

* Identifies opportunities for improved communication or processes

* May participate in audit activities and meetings

* Documents rate negotiation accurately for proper claims adjudication

* Identify and refer potential cases to Care Management

* Performs all other related duties as assigned

Qualifications:

Education:

* Nursing degree or diploma required, bachelor's degree in nursing

Preferred/Desirable:

* Bachelor's degree

* RN license in state of MA, NH or compact license

* Medicare and Medicaid knowledge

Experience:

* 2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines)

* Managed care experience

* All employees working remotely will be required to adhere to Wellenses' Telecommuter Policy

Licensure, Certification or Conditions of Employment:

* Active, unrestricted RN license in state of residence

* Pre-employment background check

* Ability to take after hours call, including evening/nights/weekends

Competencies, Skills, and Attributes:

* Strong oral and written communication skills.

* Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care.

* Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders

* Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements.

* Proficiency in Microsoft Office applications and data management systems.

* Demonstrated organizational and time management skills

* Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives

Working Conditions and Physical Effort:

* Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.

* Fast paced and dynamic work environment requiring adaptability and focus.

* Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings.

* Regular and reliable attendance is essential.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees